Question of the Week # 163

163) A 62 year old man with past medical history significant for Congestive Heart Failure presents with progressively increasing shortness of breath over the past 2 months. He denies any chest pain on exertion or at rest. He was recently started on furosemide for management of peripheral edema and is compliant with low salt diet. An Echocardiogram obtained 3 months ago revealed an Ejection Fraction of 32% (Normal = above 55%) at which time he was started on Enalapril. On physical examination, there is trace ankle edema. There are no lung crackles on auscultation. Rest of the examination is normal. An EKG reveal changes of left ventricular hypertrophy with normal QRS duration. The most important intervention at this time that would most improve his survival is

A) Start Losartan

B) Start Carvedilol

C) Start Isosorbide and Hydralazine

D) Add Digoxin

E) Biventricular Pacing

16 Responses

  1. C) Start Isosorbide and Hydralazine

    • Why would you give nitrates and Hydralazine in a patient who is having an EF less than 40? B BLOCKERS prolong survival in a Heart failure patient where the etiology is Ischemic.

    • To support your answer, I would say, yes, A-HeFT study showed 43% mortality rate reduction in African-Americans with median ejection fractions as low as 24%. Yes, AHA and CDC 2012 statistical fact sheet shows that 4.5% male, 3.8% female against the runner up 2.7%male, 1.8%female (more African Americans have heart failure) and Yes, Nitromed Inc. research study summarize a cost saving of $500-1700 over mean follow up period of 12.8 months ($37000 per life year at five year)
      But USPSTF and AHRQ report that H-ISDN significantly increases rate of heart failure hospitalizations in every other studied group( non-african american)Two, they concluded in V-HeFT study that it is not associated with significant reduction in mortality or hospitalization in any subgroups analyses ( unlike, Carvedilol, which has been shown in the COPERNICUS Trial to reduce mortality by 35% in ejection fraction less than 25% or NYHA class III and IV)
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC59648
      http://www.arhq.gov/about/highIt10b.htm (under ‘New Research report’ 2010)
      http://www.ncbi.nlm.nih.gov/pubmed/16466600
      In this case, carvedilol clearly has significant mortality benefit.
      When will I consider H-ISDN in heart failure? ( pls update me if there is more current evidence based report) If patient is African American plus one of the following scenarios;
      1. He is on all mortality lowering drugs already and is still getting worse.
      2. He can not take a mortality lowering drug because of a severe contraindication, for instance, recurrent life threatening hyperkalemia after ACE Inhibitors
      3. patient has severe copd ( FEV1 = 30-49 %) or severe asthma (FEV1<60%) now and is on Carvedilol (beta blocker) because of history of heart failure and now I must stop Carvedilol. H-ISDN (bidil) has been shown to have lower risk of adverse outcome in African-Americans (V-HeFT adopted by USPSTF 2010).
      Heart Failure Society of America 2012 annual scientific meeting has a lecture on Evidence supporting the Benefit of H-ISDN in the treatment of HF (it suggests that H-ISDN should be considered by clinicians for eligible African Americans)
      http://www.hfsa.org/hydralizine_isosorbide_dinitrate_therapy_failure.asp
      Bottom line, I will use H-ISDN as second line to mortality lowering drugs in African Americans with HF(going with standard of care and HFSA 2010 Practice guideline for HF in African Americans)This clinical practice has not been recommended as standard of care by the USPSTF (AHRQ) and is still underutilized by clinicians because of tid dosage regimen, tolerability and side effects (headache), racial controversies, poly pharmacy, multiple use of medications which lower SBP.
      I feel the answer should be B. it is the only option in the list of options that has been shown to improve survival in all patients regardless of race. If this patient is African American male, I would still say 'b' because the benefit of H-ISDN and Biventricular pacer and digoxin in acute heart failure is still theoretical. (Unconfirmed by large clinical trials).

  2. b

  3. bbb

  4. B) Start Carvedilol

  5. B……….

  6. start Losartan. The only choice that decreases mortality is a. He has ventricular hypertrophy, and starting an arb helps the remodeling of the cardiac muscle.

  7. Ans: B

    the pt. is already on ACE-Inhibitor and now we need to B-Blocker.
    The sequencing of Systolic dysfunction start with 1-Loop Diuertics (Furosamide) 2- ACE-Inh after titrating to the maximum dose we should start with B-Blocker ….

    If EF still didn’t improve with both ACE-Inh & BB we can add Hydralazine & Nitrate .

  8. B.

  9. Answer = B
    Pt with CHF and low EF should be treated with
    1. ACE inhibitor/ARB
    2. Metoprolol or Carvedilol
    3. Spironolactone
    4. other diuretice
    5. Dig
    Option A to C also decrease mortality. I would go with Carvedilol.

  10. Correction.
    Option not A to C but 1 to 3 (ACEI/ARB, Meto/Carv, Spiron)

  11. If the QRS was prolonged we would do E,

  12. answer B. All patient with heart failure start treatment with diuretic (loop), and ACEI. If he has Contraindication for ACEI, treat with hydralazine and isosorbide. Once heart failure is controled with ACEI, all patient should be treated with b blocker regardless of the pressure.
    we can add others if it is not controlled. spironolactone, then sympathomimetic Dopamine/dobutamine/PDE inhibitor, milinrone or Amrinone.

  13. B. Beta blocker reduces mortality in CHF besides ACEi

  14. Only 3 type of Tx have been shown to reduce morbidity and mortality in Pt who have CHF 1) Captopril 2) Spironolactone 3) Carvediol, Metoprolol Bisoprolol — Simple question — simple book answer –

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